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The Creative Therapy Consultants Homemaking Assessment: Administration Guide
Version 1.0 July 27, 2016
Prepared by:
Nicole Matichuk, BKIN1, Liv Brekke, MPA1, Hilary Drummond, OT(C) 2, & Susan Forwell, PhD, OT(C) 1 1Department of Occupational Science & Occupational Therapy, University of British Columbia
2Creative Therapy Consultants
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Table of Contents
BACKGROUND ......................................................................................................................... 2
ASSESSMENT FEATURES ....................................................................................................... 3
MEASUREMENT PROPERTIES ............................................................................................... 4
Population .............................................................................................................................. 4
Ecological Validity .................................................................................................................. 4
Face Validity and Acceptability ............................................................................................... 5
Content Validity ...................................................................................................................... 5
Internal Consistency ............................................................................................................... 6
Interrater Reliability................................................................................................................. 6
ADMINISTRATION AND SCORING .......................................................................................... 7
Scoring Individual Tasks ......................................................................................................... 7
Light Task Example – Folding Clothing................................................................................... 9
Medium Task Example - Cleaning the Toilet..........................................................................10
Heavy Task Example – Vacuuming .......................................................................................11
Calculating Subscale and Total Weighted Scores .................................................................12
ADDITIONAL CONSIDERATIONS ............................................................................................13
REFERENCES .........................................................................................................................14
APPENDIX A - EXAMPLE OF SCORED ASSESSMENT .........................................................15
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BACKGROUND
The Creative Therapy Consultants (CTC) Homemaking Assessment is a comprehensive, in-depth occupational
therapy assessment tool used to determine the percentage of housework tasks an individual can perform. It
was developed by Creative Therapy Consultants and has been in use for over 10 years.
Demand for the CTC Homemaking Assessment arose primarily from the need to provide a fair, objective, and
consistent approach to assessing clients who might require assistance with housekeeping tasks due to
accident or disability. While other assessments of instrumental activities of daily living (IADLs) existed at the
time, there was no tool that focused exclusively on homemaking tasks and which could provide insurance
companies, lawyers, and medical professionals with a quantifiable percentage of homemaking tasks an
individual could complete.
Individuals who have been injured in a motor vehicle accident comprise one of the primary populations with
which the CTC Homemaking Assessment is used. Results of the assessment have been used to recommend
to the insurer (often ICBC) whether or not an individual should receive additional homemaking support at
home as a result of their injuries/disability. The percentage score is particularly valuable because the
primary motor vehicle insurance agency, ICBC, provides homemaking supports only for those individuals who
can no longer perform the majority (i.e. 50 percent) of their previous homemaking tasks. The assessment has
also been used with other insurers or payers to support the credibility of clinical recommendations, and
results have been used in medical-legal assessments and discussed in court proceedings.
Key strengths of the CTC Homemaking Assessment include:
● Ecologically valid, client-centered, and occupation-based
● Tested in a broad population of ages and injuries/disabilities
● Diversity of items assessed in terms of the potential physical and cognitive demands of
homemaking tasks
● Weighting system which helps to capture the relative differences in difficulty between tasks
● Psychometric data showing good internal consistency
● Well-accepted by clinicians, fee payers, and the legal system
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ASSESSMENT FEATURES
The following table provide a brief overview of the administration, applications, and content of the CTC
Homemaking Assessment. An example assessment can also be found in Appendix A.
Procedures Client-therapist interview supplemented by In-home observation of task performance
Setting
Chronic or acute
Populations
Physical, cognitive, mental health issues
Content 29 tasks divided into 3 categories: a. Light: 8 tasks (e.g. dusting, chopping food, folding clothes) b. Medium: 12 tasks (e.g. ironing, washing dishes, cleaning toilet) c. Heavy: 9 tasks (e.g. vacuuming, cleaning bathtub, grocery shopping) Permits addition or deletion of items based on client’s occupational profile
Scoring Simple weighting and scoring system that captures differences in task difficulty (see Scoring section of this guide for further details)
Time to Administer 1-2 hours
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MEASUREMENT PROPERTIES
The following synopsis of measurement properties is based on a study conducted in 2015-2016 by a student,
clinician, and faculty research team with the Department of Occupational Science and Occupational Therapy
at the University of British Columbia. The study examined aspects of the validity and reliability of the
Assessment using a retrospective chart review and a small prospective sample of clients. Validity is the
degree to which an assessment measures what it is intended to measure (Law & Letts, 1989). Reliability
refers to the stability, consistency, and dependability of an instrument’s measurements (Law, 1987).
Specific results of the UBC study and their implications for administering the CTC Homemaking Assessment
are described below, along with additional information which can help inform clinical use of the Assessment.
Population
The CTC Homemaking Assessment has been effectively used with a broad range of individuals. In the sample
client population (n=113) from the UBC study, the mean age was 50.6 ± 15.2 years, and clients ranged in age
from 19 to 92. Two-thirds of these individuals were female; thus some caution is warranted in terms of
generalizing the reliability and validity of the assessment to men.
To date, the Assessment has been used extensively with clients who have experienced a motor vehicle
accident (MVA). It is therefore particularly applicable and reliable for use with this population. The
assessment has also been used with clients referred for falls, life care planning, and medical-legal
assessment, and to a lesser extent for functional capacity evaluations and return to work planning.
The assessment has also been used with clients with a wide range of diagnoses. Some of the most common
of these have been pain (including headaches), fracture and/or joint issues, soft tissue injuries (including
whiplash), and mental health diagnoses (anxiety, depression, PTSD, and adjustment disorder). The
Assessment has also been used with individuals with sensory changes (hearing and vision loss, peripheral
sensation changes), head injuries and/or cognitive issues (hemorrhage, TBI, concussion), and chronic disease.
Most clients who have undergone the CTC Homemaking Assessment have had multiple (2+) diagnoses.
Ecological Validity
Individuals participate in tasks or activities within their own unique physical, social, institutional, cultural and
temporal context. Therefore, the assessment environment will have an influence on a person’s performance
(Law, Baum, & Dunn, 2005). Research suggests that assessments of everyday activities should occur in the
environment in which the client usually completes them (Rogers et al., 2013; Law, Baum, & Dunn, 2005). The
CTC Homemaking Assessment is administered in the client’s own home; it is therefore grounded in the
client’s own context and can be said to have good ecological validity.
Similarly, the CTC Homemaking Assessment is also client-centered, and can account for differences in the
patterns of homemaking tasks each individual completes. The Assessment does this by allowing clinicians to
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add tasks if necessary, and to score existing items as “not applicable” if it is a task not typically done by the
client (e.g. handwashing clothes) or if the client’s unique environment does not allow them to complete this
task (e.g. they do not have a dishwasher).
Face Validity and Acceptability
Clinicians who have used the CTC Homemaking Assessment to date have consistently provided positive
feedback about it. It provides a clear framework for assessment, more evidence upon which to base clinical
recommendations, and also assists with treatment planning. In addition, the assessment has been well-
accepted by insurers and lawyers. Because it has been reviewed by experts and determined to be credible,
the assessment can be said to have good face validity and clinical acceptability.
Content Validity
Content validity is the extent to which an instrument’s items comprehensively represent all the
characteristics of a construct or concept it is designed to measure (Mokkink et al., 2010; Yuen & Austin,
2014). One way of establishing content validity is through expert opinion (Mokkink et al., 2010. If clinicians
judge that the assessment tool comprehensively measures the thing it is intended to measure, then the tool
can be said to have content validity.
The CTC Homemaking Assessment is designed to measure the construct of homemaking ability, and the
development process of the Assessment supports its content validity. It was initially developed through
collaboration between six CTC occupational therapists. The team of therapists began by establishing a list of
homemaking tasks that were common to the clients they were seeing in practice, particularly those tasks
with which clients had the most difficulty. The team then classified the tasks as light, medium, or heavy to
reflect the relative demands of the different homemaking activities. Therapists then began to trial the
assessment and would reconvene as a group to discuss how it had worked in practice and consider
modifications that could be made. The assessment was regularly evolving for the first couple of years, and
the list of tasks on the assessment has continued to be adjusted throughout its years of use, as has their
categorization.
Content validity can also be established by using statistics (Mokkink et al., 2010). Correlational analyses
conducted during the UBC study demonstrated that, as expected, the entire assessment measures a single
construct overall, i.e. homemaking. All three subscales (light, medium, and heavy) demonstrated a moderate
to strong positive relationship with each other. Individual assessment items also showed consistently
positive relationships with each other, suggesting that the scale overall is generally unidimensional (i.e.
assesses homemaking and nothing else).
Results from the UBC study also demonstrated the validity of the subscales themselves. The correlations
between subscale scores were stronger between light and medium scores, and between medium and heavy
scores, than between light and heavy scores. This suggests that there is indeed a gradient in task difficulty,
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as the assessment intended. Moreover, over two-thirds of clients with whom the assessment has been
administered have demonstrated decreasing performance as task difficulty increased, thus reinforcing the
distinction between the subscales.
Not only does the assessment include homemaking tasks with a range of difficulty levels, but also tasks
which place different kinds of performance demands on individuals. Factor analysis results from the UBC
study identified several additional sub-constructs across assessment items. These constructs, or factors,
suggested more specific physical and cognitive requirements involved in completing a task. Identified
categories of task demands included: bending tasks, upper extremity tasks, manipulating loads, and planning
tasks. The implications of these additional constructs are discussed in the Administration and Scoring section
of this guide.
Internal Consistency
Internal consistency refers to the sameness of items or scores within an instrument (Law & MacDermid,
2014) and is a type of reliability. Research into the CTC Homemaking Assessment shows that all three
subscales have demonstrated adequate to good internal consistency. In a sample of 113 clients, Cronbach’s
alpha values were as follows: 0.78 for light tasks; 0.77 for medium tasks; and 0.80 for heavy tasks. An alpha
value above 0.70 is considered adequate, 0.8-0.9 good, and above 0.9 excellent (Vroman & Stewart, 2014).
Therefore, clinicians can say that the assessment’s subscales consistently and reliably measure homemaking
tasks of light, medium, and heavy difficulty.
Interrater Reliability
Interrater reliability assesses how consistently an assessment performs when administered by different
practitioners (Vroman & Stewart, 2014). As part of the UBC study, researchers examined interrater
agreement in a small sample (n=9) of clients. Subscale scores assigned to the same client by two different
raters, a student and a clinician, were compared. The smallest mean difference in subscale scores between
the two raters was 6.3 ± 6.3 percent, and the largest mean difference was 8.1± 11.5 percent. This
preliminary information is promising, but further research is required in order to confidently quantify the
strength of the assessment’s interrater reliability.
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ADMINISTRATION AND SCORING
As with any other measure, administration of the CTC Homemaking Assessment should begin with explaining
the purpose and implications to the client, responding to any questions, and obtaining and documenting
consent.
The clinician typically begins by working through the items on the assessment via interview with the client,
documenting scores and qualitative information as they go. Clients are then asked to demonstrate only
some of the tasks in the assessment. For this performance-based component, it is recommended that the
clinician choose tasks that the client expresses more difficulty in completing. This likely means observing
more medium and heavy tasks than light ones. Scores should be recorded as the clinician observes client
performance of the task. Any other pertinent information, such as reports of pain or use of adaptive aids,
should also be noted in the space provided on the assessment form. The number of tasks observed (versus
relying on self-report) is at the discretion of the clinician.
Based on results of the UBC study, clinicians should consider not only the task difficulty, but also the
underlying type of task demand when selecting tasks to observe. Clinicians should observe homemaking
tasks that place varying types of physical demands (bending, upper extremity work, and managing loads) and
cognitive demands (planning/organizing) on clients in order to obtain the most comprehensive picture of the
client’s overall homemaking ability. For example, if a client struggles to complete a medium bending task
(e.g. cleaning the toilet), the clinician administering the assessment may wish to also observe a medium
upper extremity-based task (e.g. washing dishes) because the two tasks may reveal different performance
abilities.
Scoring Individual Tasks
Each task is scored out of 1, where 1 represents full, complete, independent performance of the
homemaking task. A score of 0.5 generally represents incomplete or inadequate performance on the task,
while a score of 0 means the client is unable to complete the task at all.
If a client does not perform a task (e.g. they do not have a dishwasher, or they never clean the windows),
then the task should be marked “not applicable” or “N/A”. These tasks will not be included in the
assessment totals.
In addition, questions about pain, fluctuating performance, compensations, and safety should be scored as
follows:
● The client can complete the task but is in pain
If the client can complete the whole task, but is in pain, their score should be either a 1 or 0.5. The
score depends on how long it took the client to complete the task, how safe the client was, and the
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degree of pain. The longer the completion time, the less safe the performance of the task, and the
higher the degree of pain, the lower the score should be.
● The client could complete the task once, but performance decreased or fluctuated over the course
of the assessment
A score of 0.5 is suggested.
● The client can complete the task using compensatory strategies or aids
A score of 1 is suggested. Note the clinician should record the aids/methods the clients used directly
on the CTC Homemaking Assessment form.
● The client can complete the task but your clinical judgment suggests that it is unsafe for them to
continue to do so.
A score of 0.5 is suggested. Clinicians should record that “the client is not safe and should not do this
task” on the assessment form. Safety recommendations should be communicated directly to the
client and further documented by the clinician.
Clinicians should thoroughly document the occurrence of the above listed events and/or limiting factors on
the assessment form in order to support their score.
To further support clinicians in consistently scoring assessment items, the following pages provide brief case
studies of how to score example tasks from each of the subscales.
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Light Task Example – Folding Clothing
Case Study 1 (brain injury):
Suzy has had a brain injury. Her symptoms are fatigue,
dizziness, and executive functioning difficulties such as
organization, problem solving and prioritizing. She
cannot get herself organized to perform her household
tasks and fatigues quickly when doing much at one time.
She is also experiencing right-sided weakness.
Case Study 2 (musculoskeletal injury):
Fred has been in a motor vehicle accident. He has a
fractured right hip and spine. His symptoms are pain in his back, restricted movement, and limited mobility
while in his wheelchair.
Suzy Fred
0 Physical: Unable to fold any clothes at all as
her right hand cannot hold onto the fabric
OR
Cognitive: unable to problem solve a
technique for folding clothing in the same
manner
Unable to access laundry basket of
clothes and unable to reach down to
pull clothes out of basket.
0.5 Physical: Able to fold smaller items, such as
clothing, but cannot fold sheets and towels
due to restricted right arm function.
Cognitive: Folds clothes into impractical
shapes for putting away.
OR
Can figure out how to fold socks and
underwear but not shirts and pants.
Able to fold smaller items when laundry
is moved right beside him.
1 Able to fold all items without difficulty. Able to fold all items without difficulty.
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Medium Task Example - Cleaning the Toilet
Case Study 1 (brain Injury):
Suzy has had a brain injury. Her symptoms are fatigue,
dizziness, and executive functioning difficulties such as
organization, problem solving and prioritizing. She cannot get
herself organized to perform her household tasks and fatigues
quickly when doing much at one time. She is also experiencing
right-sided weakness.
Case Study 2 (musculoskeletal injury):
Fred has been in a motor vehicle accident. He has a fractured
right hip and spine. His symptoms are pain in his back,
restricted movement, and limited mobility while in his
wheelchair.
Suzy Fred
0 Physical: Unable to perform task at all as
cannot lean over the toilet without
getting dizzy and falling- safety risk
Unable to perform task at all as cannot
reach area or bend over to clean.
0.5 Physical: Able to clean top part of toilet,
but cannot reach down into toilet or
clean bottom area,
Cognitive: Able to wipe down the toilet
but doesn’t remember to clean the bowl,
or requires cueing to wipe down all parts
and clean bowl
Able to wipe down top of toilet, unable
to reach lower areas.
1 Able to clean all of toilet without difficulty
Able to clean all of toilet without
difficulty
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Heavy Task Example – Vacuuming
Case Study 1 (brain Injury):
Suzy has had a brain injury. Her symptoms are fatigue, dizziness,
and executive functioning difficulties such as organization,
problem solving and prioritizing. She cannot get herself
organized to perform her household tasks and fatigues
quickly when doing much at one time. She is also
experiencing right-sided weakness.
Case Study 2 (musculoskeletal injury):
Fred has been in a motor vehicle accident. He has a
fractured right hip and spine. His symptoms are pain in
his back, restricted movement, and limited mobility while in
his wheelchair.
Suzy Fred
0 Physical: Unable to do any vacuuming;
cannot move vacuum.
Cognitive: Cannot operate vacuum
cleaner controls, or sequence properly
(plug in, turn on, and operate).
OR
Does not initiate task at all.
Unable to vacuum at all.
0.5 Physical: Able to vacuum smaller flat
areas. Cannot vacuum stairs and/or
cannot move furniture to vacuum
underneath it.
Cognitive: Vacuums obvious areas but
does not move furniture.
OR
Perseverates and goes over the same
areas many times.
Able to vacuum small areas with
lightweight vacuum, or cannot move
vacuum very far.
1 Able to vacuum all areas independently. Able to vacuum all areas in his home. He
has no stairs.
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Calculating Subscale and Total Weighted Scores
1. Establish the total number of tasks that were applicable to a client in each subscale. If a client does not
do a task, and did not do this task before their injury, that task is marked N/A and not included in the
total. For example, the light subscale includes 8 possible tasks. However, one is not applicable to the
client (e.g. because the husband has always swept the floor). Therefore the client’s light task score would
be divided by 7, not by 8.
2. Add up the scores (i.e. 0, 0.5, or 1) assigned to each of the tasks. Complete this for each subscale: light,
medium, and heavy. For example, the client’s scores in the light subscale could be 0, 0.5, N/A, 1, 1, 1,
0.5, 1 = 5
3. Calculate the percentage of tasks the client was able to complete for each subscale. For example, if the
client scored 5/7 for light tasks, this would be 71.43%. Do this for light, medium and heavy tasks:
Light tasks 5/7 = 71.43%
Medium tasks 6/10 = 60%
Heavy tasks 5/9 = 55.56%
4. Complete the weighting multiplication for each of the subscales. The light task percentage score is
multiplied by 1, the medium task percentage score by 2, and the heavy task percentage score by 3.
Light tasks 5/7 = 71.43% x 1= 71.43
Medium tasks 6/10 = 60% x 2 = 120
Heavy tasks 5/9= 55.56% x 3= 166.67
5. Add up the total weighted scores from each subscale. For the example listed above, this would equal:
71.43 + 120 + 166.67= 358.1
6. To calculate the final weighted percentage, divide by 6 (because the scores were multiplied by 1, 2, and
3 earlier). From the example listed above, 358.1/6 = 59.68%
59.68% is the final weighted percentage of homemaking tasks that the client can perform.
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ADDITIONAL CONSIDERATIONS
The CTC Homemaking Assessment is intended to support, but not replace, clinical judgment and should not
form the sole basis for decisions about recommending in-home supports. Administering the tool effectively
requires the clinician to critically observe the consistency of the findings, as there is potential for the client to
try to skew the results. For example, a clinician might question a client further if the client indicates that
they can do no light or medium tasks, but can, in fact, complete several heavy tasks. Similarly, a clinician
might ask additional questions if a client reports they can perform a task, but the clinician observes them
having difficulty with much easier tasks.
14
REFERENCES
Law, M. (1987). Measurement in occupational therapy: Scientific criteria for evaluation. Canadian Journal of
Occupational Therapy, 54(3), 133-138. doi:10.1177/000841748705400308
Law, M. C., Baum, C. M., & Dunn, W. (2005). Measuring occupational performance: Supporting best practice
in occupational therapy. Thorofare, NJ: SLACK Inc.
Law, M., & Letts, L. (1989). A critical-review of scales of activities of daily living. American Journal of
Occupational Therapy, 43(8), 522-528.
Law, M. C., & MacDermid, J. (2014). Evidence-based rehabilitation: A guide to practice. Thorofare, NJ: Slack.
Mokkink, L. B., Terwee, C. B., Patrick, D. L., Alonso, J., Stratford, P. W., Knol, D. L., . . . de Vet, H. C. W. (2010).
The COSMIN checklist for assessing the methodological quality of studies on measurement properties
of health status measurement instruments: An international delphi study. Quality of Life Research,
19(4), 539-549. doi:10.1007/s11136-010-9606-8
Rogers, J., Holm, M., Beach, S., Schulz, R., Cipriani, J., Fox, A., & Starz, T. (2003). Concordance of four
methods of disability assessment using performance in the home as the criterion method.
Arthritis & Rheumatism-Arthritis Care & Research, 49(5), 640-647. doi:10.1002/art.11379
Vroman, K., & Stewart, E. (2014). Occupational therapy evaluation for adults: A pocket guide. Baltimore:
Lippincott Williams & Wilkins
Yuen, H. K., & Austin, S. L. (2014). Systematic review of studies on measurement properties of instruments
for adults published in the American Journal of Occupational Therapy, 2009-2013. The American Journal
of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 68(3),
e97. doi:10.5014/ajot.2014.011171
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APPENDIX A - EXAMPLE OF SCORED ASSESSMENT
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